EDITORIAL: THC can't help PTSD, experts say
For every military veteran appearing in a Colorado public meeting to advocate for the right to use marijuana to treat post-traumatic stress disorder, mental health professionals throughout Colorado estimate they've worked with thousands whose pot use made their PTSD - and their lives in general - much worse.
"I have seen marijuana use create so many more problems than it solves," said Brian Lanier, a licensed clinical social worker and Army reservist in Colorado Springs who has worked more than 15 years with veterans and active-duty service members. "If nothing else, these people are just numbing themselves, which is definitely not appropriate treatment for PTSD. Telling someone to use marijuana for PTSD or any mental health problem is like telling them to go get drunk."
His sentiments are shared by mental health professionals nationwide, as physicians most qualified in the treatment of PTSD and mental illness have mounted protests against a recommendation by the Colorado Department of Public Health and the Environment to add PTSD to the list of conditions qualifying for access to "medical marijuana." A rule-making hearing that includes public testimony is set for Wednesday in Denver. The Colorado Psychiatric Society and the Colorado Child and Adolescent Psychiatric Society lodged letters of protest - as did Dr. Kenneth Finn, a Colorado Springs physician who specializes in pain medicine.
"(PTSD) is complex and not easily treated by physicians, particularly those with no psychiatric background," Finn stated in his letter to the CDPHE. "As a pain medicine physician, I see many patients with the diagnosis who are being co-treated by a psychiatrist. I would not feel comfortable trying to manage a patient's medications with this diagnosis. If PTSD reaches the bar of a 'disabling condition' in Colorado, it will give free reign to any physician or any doc-in-the-box with no background in psychiatry to recommend cannabis for these patients. The potential negative sequelae [corollaries] are huge."
And they move far beyond serious questions about physicians who practice outside the scope of their training and the potential liabilities they face should something go wrong.
Marijuana, dried parts of the cannabis plant that are typically smoked, and extracts of concentrated THC, the leading active ingredient of cannabis that produces a euphoric high and commonly is infused in foods and drinks and vaporized through electronic cigarette devices, aren't shaping up to be so medical, researchers say. In June, the Journal of the American Medical Association published reports from an international team of researchers who conducted a comprehensive review of dozens of clinical trials testing marijuana, a psychoactive drug, for 10 conditions. They found very little reliable evidence to support the drug's medicinal use and warned that users are at greater risk of having psychiatric disorders and other health problems.
State laws sanctioning marijuana for medical reasons have "relied on low-quality scientific evidence, anecdotal reports, individual testimonials, legislative initiatives and public opinion," two psychiatrists at Yale University wrote in a supporting editorial. "Imagine if other drugs are approved through a similar approach." Drs. Deepak Cyril D'Souza and Mohini Ranganathan noted that state approvals of marijuana for medical use have outpaced research and should wait for stronger evidence of efficacy and safety. Federal and state governments should support and encourage such research, they added.
"Perhaps it is time to place the horse back in front of the cart," the doctors wrote.
Where the treatment of PTSD is concerned, the State of Colorado certainly has opportunity and reason to do so. It has awarded a research grant to evaluate marijuana's effects on PTSD treatment, and the work is just getting underway. That is "all the more reason for officials with the CDPHE, Colorado Board of Health and state lawmakers to reserve judgment about marijuana's efficacy (for PTSD) until that work is complete and also evaluated within the larger context of the world body of medical literature by professionals with appropriate formal training and expertise to do so," wrote Dr. Christian Thurstone on his website. An associate professor of addiction psychiatry at the University of Colorado, who directs medical training for the addiction psychiatry fellowship program, Thurstone serves as a major in the U.S. Army Reserves and on the board of Smart Approaches to Marijuana (SAM) - which he joined after seeing increasingly detrimental effects marijuana had on his patients.
"If we're genuinely concerned about the mental health of our service members and veterans, we should demand nothing less than easy, affordable access to the psychotherapies and pharmacotherapies that have proven to be safe and effective - and we should reject marijuana until it meets those standards," Thurstone added.
The world has seen the manipulation of military service members for drug-industry gain in the past. Tobacco smoking's close ties to the American military started during World War I. At the time, national smoking rates were low. To gain market traction, tobacco companies targeted military personnel, even setting up funds where Americans could express their support for the war effort by purchasing smokes for soldiers.
Fast forward to Jan. 1, 2014, when the first purchase of state-sanctioned, recreational marijuana - carefully staged for reporters and cameras - was made by a Denver-based Iraq War veteran who claimed to have PTSD and said he needed marijuana to alleviate his symptoms.
Intensive therapy is hard work - and it is a core component of PTSD treatment, psychiatrists and other PTSD treatment specialists say. Marijuana users mask problems without addressing the underlying causes of the stress, anxiety, fear and anger that keep them in a continual state of emotional distress. If they're under the drug's influence, therapy is nearly impossible, and the symptoms of PTSD - a condition that in most cases lasts less than a year with rigorous therapy - worsen, said Dr. Stuart Gitlow, immediate past president of the American Society of Addiction Medicine.
"Psychoactive substance use will generally lead to a deteriorating course and treatment failure," Gitlow said.
That is why many mental health specialists working for Veterans Affairs treatment centers across the country prioritize the care of sober veterans ahead of active users of illicit drugs, including marijuana. A few such specialists spoke with The Gazette on the condition of anonymity because they fear professional discipline for sharing their views of an issue they say is used more now to advance drug-legalization politics than patient care.
"There are too many people coming in here who sincerely want the help, and they're sober, and they're ready to do whatever it takes to be well," said one VA psychologist working in California. "When I'm dealing with a marijuana user, I have to be honest from the start and tell them I'm not going to waste my time, theirs or the American taxpayers' money on weeks of therapy that is set up for failure. I'm going to work with that vet however I can, but I'm not going to pretend their marijuana use is medicine."
Neither will Lanier, a psychotherapist in Colorado Springs.
"I want to give people good, quality treatment and not just a drug that makes them go away," he said. "Supporting people in their efforts to remain in a constant state of sedation is not helping them. It's hurting them."
The CDPHE has given several reasons to justify its recommendation that PTSD be added to the list of qualifying conditions for medical marijuana use - and none of them sit well with Dr. Doris Gundersen, a Denver psychiatrist with extensive experience in PTSD treatment. For example, the department rightly notes there are only two drugs approved by the U.S. Food and Drug Administration for treating PTSD, and several other FDA-approved drugs are used "off label." This, the department asserts, shows that "conventional treatments are not all subject to the same rigorous process of review and approval."
However, Gundersen said, the crucial difference is that marijuana is not FDA approved. She's backed up by the physicians whose analyses of marijuana's efficacy were recently published in JAMA. "Unlike most FDA- approved drugs that typically have one or two active constituents, marijuana is a complex of more than 400 compounds . including . cannabinoids that have individual, interactive and even entourage effects . that are not fully understood," the researchers wrote. And also unlike FDA- approved drugs, cannabis' strains and preparations vary wildly, making it very difficult, if not impossible, to replicate marijuana exactly and dose it precisely.
The CDPHE also claims adding PTSD to the list of qualifying medical conditions would allow it to "obtain more accurate information from applicants (for medical marijuana), and will improve the department's understanding of . patients' medical marijuana needs."
"That is not a very scientific method for examining the needs of patients," Gundersen said.
" . If the states' initiatives to legalize medical marijuana is merely a veiled step toward allowing access to recreational marijuana, then the medical community should be left out of the process and instead marijuana should be decriminalized," researchers wrote in the JAMA editorial. "Conversely, if the goal is to make marijuana available for medical purposes, then it is unclear why the approval process should be different from that used for other medications."
The U.S. Department of Veterans Affairs' National Center for PTSD: The center confirms there is no evidence that marijuana use is an effective treatment for PTSD. "The percentage of veterans in (the VA system) with PTSD and (Substance Use Disorder) who were diagnosed with cannabis use disorder increased from 13 percent in fiscal year 2002 to 22.7 percent in fiscal year 2014 . "
- The Vermont Agency of Human Services Department of Health: The state of Vermont rejected political efforts to add PTSD to the list of "qualifying conditions" for state-sanctioned marijuana use. In January, the department reported: "Marijuana is not an evidence-based treatment for PTSD and in fact has been shown to interfere with otherwise effective, evidence-based cognitive behavioral therapy protocols. Individuals with diagnosed PTSD who request medical marijuana typically have extensive additional lifetime and current substance abuse disorders. Recent reports suggest even non-dependent 'recreational' marijuana use among young adults has been shown to adversely and likely permanently affect brain structures which can lead to detrimental later outcomes (e.g. more illicit drug use, early onset memory problems, etc.). Review the full report on gazette.com.
- The American Psychiatric Association: "Because of the lack of any credible studies demonstrating clinical effectiveness, the APA cannot endorse the use of medical marijuana for the treatment of post-traumatic stress disorder (PTSD) . " Review statement on gazette.com.
- The Colorado Psychiatric Society: The society strongly opposes legislative efforts to add PTSD to the list of medical conditions qualifying for state-sanctioned marijuana use. Dr. Doris Gundersen, a past president of the society, said giving marijuana to a PTSD patient is "like crushing 15 kinds of antidepressants and dispensing them." Review the full statement on gazette.com.
- "Marijuana Use is Associated with Worse Outcomes in Symptom Severity and Violent Behavior in Patients with PTSD" - Samuel T. Wilkinson, M.D.; Elina Stefanovics, Ph.D.; Robert A. Rosenheck, M.D., Yale University School of Medicine, 2014. (Longitudinal, observational study of 2,276 veterans admitted with PTSD to VA treatment programs). After adjusting for relative baseline covariates, "marijuana use was significantly associated with worse outcomes in PTSD symptom severity, violent behavior and measures of alcohol and drug use . Marijuana may actually worsen PTSD symptoms . "
About the report
Clearing the Haze is a special report produced by Gazette editorial board members Wayne Laugesen and Pula Davis in collaboration with Christine Tatum, a veteran journalist and former national president of the Society of Professional Journalists. Tatum is married to Dr. Christian Thurstone, medical director of one of Colorado's largest youth substance abuse treatment clinics.
To read previous installments of Clearing the Haze, go to gazette.com/clearing thehaze.